REVIEW
Standardized tests of handwriting readiness: a systematic review
of the literature
MARGO J VAN HARTINGSVELDT 1 , 2 | IMELDA J M DE GROOT 1 , 2 | PAULINE B M AARTS 3
|
MARIA W G NIJHUIS-VAN DER SANDEN 1 , 4
1 Radboud University Nijmegen Medical Centre, Nijmegen Centre for Evidence Based Practice, Nijmegen, the Netherlands. 2 Department of Rehabilitation, Nijmegen, the
Netherlands. 3 Department of Research, Development and Education, Sint Maartenskliniek Nijmegen, Nijmegen, the Netherlands. 4 Scientific Institute for Quality of Health Care,
Nijmegen, the Netherlands.
Correspondence to Margo J van Hartingsveldt at Department of Rehabilitation, Occupational Therapy 898, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen,
the Netherlands. E-mail: m.vanhartingsveldt@reval.umcn.nl
PUBLICATION DATA
AIM To establish if there are psychometrically sound standardized tests or test items to assess
Accepted for publication 5th November 2010.
Published online 11th February 2011.
handwriting readiness in 5- and 6-year-old children on the levels of occupations activities ⁄ tasks
and performance.
METHOD Electronic databases were searched to identify measurement instruments. Tests were
included in a systematic review if: (1) participants are 5 and 6 years old, (2) the focus was on
handwriting readiness, and (3) the measurement was standardized. In the second step a further
electronic search was undertaken for selected relevant measurement instruments to evaluate the
content, psychometric properties, and feasibility of these instruments.
RESULTS The search identified 1113 citations. In the final selection 39 articles with information
about 12 tests were included. The content, feasibility, and psychometric properties of these 12
tests were evaluated and none of the instruments was satisfactory, according to the specific
criteria.
INTERPRETATION None of the instruments include all necessary components to evaluate writing
readiness. Therefore, the development of an all encompassing assessment is necessary to test
handwriting readiness and to make tailored interventions possible.
ABBREVIATIONS
ADL
Beery VMI
Activities of daily living
Beery Developmental Test of
Visual Motor Integration
BOT-2
Bruininks–Oseretsky Test of
Motor Proficiency, 2nd edition
CINAHL
Cumulative Index to Nursing
and Allied Health Literature
DAP:QSS
Draw-A-Person: Quantitative
Scoring System
Denver-II
Denver Developmental
Screenings Test, 2nd edition
ERIC
Education Resources
Information Center
MMT
Maastricht's Motor Test
MPC
Motor Performance Checklist
M-ABC-2
Movement Assessment Battery
for Children, 2nd edition
9HPT
Nine Hole Peg Test
SCRIPT
Scale of Children's Readiness
in Printing
School-AMPS School Assessment of Motor
and Process Skills
TCOP
Taxonomic Code of
Occupational Performance
TIHM-R
Test of In-Hand Manipulation–
revised
WESS-P
Writing Essential Skill
Screener–Preschool version
Competent handwriting is one of the most important skills
that children learn during their first years at school.1,2 Handwriting is a major occupation in childhood that is essential
for the child’s participation in the classroom environment.3
Thirty to sixty percent of the school day is devoted to fine
motor activities, with writing as the predominant task.4,5 The
prevalence of handwriting problems has been estimated to
range between 5% and 27% depending on grade, selection
criteria, and assessment instruments used.6–10
506 DOI: 10.1111/j.1469-8749.2010.03895.x
The transition from kindergarten to elementary school is
an important period of childhood. Early school success and
positive transition tends to translate into higher levels of
social competence and academic achievement that remain
stable over time.11–13 Reducing the problems in pre-writing
skills in kindergarten children is crucial: research has shown
that a child’s healthy adjustment to school during these first
years is a precursor to subsequent school success.14–16 Educators and paediatric therapists attempt to identify children
ª The Authors. Journal compilation ª Mac Keith Press 2011
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DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY
OCCUPATION-BASED ASSESSMENT
A recent trend in occupational therapy is to focus assessment
on real-life situations, making the performance assessment
contextual and meaningful.21 The strong shift to adopt an
occupation-based approach in the assessment of children is
based on the paradigm that the evaluation should determine
how children participate in occupations in a relevant context.22
Therefore, pre-writing activities should be assessed in the natural school setting of the child where the influence of the environment can be taken into account. Subsequent analyses of
the assessment results can then consider how environmental
features support performance or create barriers. Each child
reacts differently to environmental variables; what might support performance in one child can be a barrier to performance
in another.23
In paediatric occupational therapy the focus of the intervention is on daily occupations in play, activities of daily living
(ADL), and school. In occupational therapy, occupations are
defined as a set of activities meaningful to the child in a specific context; the activities comprise a set of tasks, and the tasks
consist of a set of performance components. This hierarchy is
based on the Taxonomic Code of Occupational Performance
(TCOP).24,25 According to the TCOP, handwriting readiness
can be assessed at the level of occupations, activities, tasks, and
performance components (Table I).
Next to occupation, at the level of activities and tasks, an
assessment of writing readiness should contain an observation
of ergonomic factors, such as body position and pencil grip.
Parush et al.26 noted that children who had poor handwriting
had an inferior pencil grip paper and body positioning compared with children with good handwriting. Rosenblum
et al.27 described a high correlation between body position
and the fluency of handwriting. Subsequent studies, however,
found that that grip affected neither legibility28 nor the
What this paper adds
• An overview of tests that assess aspects of writing readiness in 5- and 6year-old children.
• An overview of the content, feasibility, and psychometric properties of 12 tests
that assess aspects of writing readiness.
• The importance of assessment in the context of a child's natural classroom
setting.
undertaking of writing long passages,29 although these studies
did not take into account the dynamic aspect of the adopted
grips.30 Kindergarten is an important period for the development of wrist stabilization in extension position and a
dynamic pencil grasp. Between the ages of 3 and 6 years,
most children develop from a transitional static grasp with
wrist movements to a mature dynamic grasp with thumb and
finger movements.31 Information about pencil grip and the
position of the wrist and the forearm resting on the surface
has to be evaluated because of early remediation. This is
important to prevent correction of the inefficient wrist position and grip after it has been reinforced and kinesthetically
locked in. At the level of performance components, empirical
evidence suggests that problems in handwriting relate to a
deficit in perceptual–motor function. The motor and perceptual components related to poor handwriting performance
may include fine motor control, visual motor integration,
visual perception, kinesthesia, and sensory modalities.19,32
Feder and Majnemer19 state in their review that the correlation between visual perception, kinesthesia and sensory
awareness of the fingers with handwriting remains unclear.
On the other hand, there is evidence for a correlation
between fine motor control, visual motor integration, and
handwriting. Several studies have found that children with
handwriting problems show a deficit in fine motor control,7,8,32,33 whereas in other studies, visual motor integration
was found to contribute significantly to poor handwriting.5,7,32,34,35 Volman et al., in their study of 29 children in
grades 2 and 3 with handwriting problems and 20 children
without handwriting problems, support the concept that there
are two different mechanisms underlying the quality of handwriting in children: fine motor coordination and visual motor
integration. The findings of this study suggest that the
Table I: Levels of occupation-based assessment
Level of
complexity
Definition
Example
Writing own name in the
classroom
Activity
An activity or set of
activities that is given
meaning by individuals
in a specific context
A set of tasks
Task
A set of functions
Performance
components
Perceptual-motor
function
Occupation
‘Drawing’ the letters on a
paper
Grasping and positioning
the pencil in the hand
Fine motor coordination,
visual motor integration
Adjusted to the Taxonomic Code of Occupational Performance
(TCOP).24,25
Review
507
14698749, 2011, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2010.03895.x by Cochrane Philippines, Wiley Online Library on [02/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
who are at risk of writing problems at an early age in order
to provide additional instruction or therapeutic intervention.13,14,17 Kindergarten children are often referred to occupational or physical therapists for evaluation and ⁄ or
treatment of poor fine motor performance, including difficulty with pre-writing skills. Therapy referrals made early in
a child’s academic career are considered to be beneficial to
the child so that a deficit can be addressed – and hopefully
corrected – before the student’s academic performance is
affected.18 In their review on handwriting remediation studies, Feder and Majnemer19 concluded that most studies on
handwriting remediation provide evidence to support its
effectiveness despite variations in the duration, frequency,
and treatment approaches applied.
The negative effects of handwriting difficulties on a child’s
academic performance and self-esteem, as discussed in the literature,14,17,20 make early evaluation of pre-writing skills of
major importance. Such early evaluations provide the kindergarten teacher with the opportunity to stimulate paper-andpencil tasks and, if major problems in pre-writing skills are
identified, to refer the child to a paediatric occupational or
physical therapist.
METHOD
Search strategy
In November 2009 we undertook a comprehensive search of
computerized bibliographic databases, including Pubmed
(1966–November 2009), Cumulative Index to Nursing and
Allied Health Literature WebSPIRS (CINAHL; 1982–
November 2009), PsychINFO WebSPIRS (1966–November
2009) and Education Resources Information Center WebSPIRS (ERIC; 1966–November 2009). Our broad search
strategy included Medical Subject Headings (MeSH) or
indexed terms as well as free-text words for ‘standardized
measurements’ AND ‘kindergarten children of 5 and 6 years
old’ AND ‘school occupations’ OR ‘school activities’ OR
‘paper-and-pencil tasks’ AND performance components,
such as ‘fine motor coordination’ OR ‘visual motor integration’ (Table SI, published online). Because we conducted
a comprehensive review, with the purpose of finding as many
references to different tests or test items as possible, we
included all study designs, such as psychometric articles and
intervention studies. The names of identified instruments
were used as terms for a further search of the electronic databases. Additional potentially relevant publications were
searched manually through citation and author tracking.
Inclusion and exclusion criteria
Tests or test items were included in the review if they met all
of the following criteria: (1) participants are kindergarten children aged 5 and 6 years, (2) handwriting-readiness specific
(i.e. items on school occupations, school activities, paper-andpencil tasks, fine motor coordination, and visual motor integration), and (3) a standardized measurement was mentioned
in the publication. Tests or test items were excluded if they
were not published in English, German, or Dutch and did not
meet the inclusion criteria.
Data extraction
A preliminary selection, based on title and abstract, was performed independently by two of the reviewers (MvH, PA).
Where there was disagreement, a decision was reached by
consensus of the reviewers. Full-text articles that fit the inclusion criteria were retrieved for more detailed evaluation by the
first author. Tests or test items were included after agreement
by both raters, and conflicting viewpoints were discussed until
agreement was reached. Assessment manuals were sourced,
and a further electronic search was undertaken for included
measures.
508 Developmental Medicine & Child Neurology 2011, 53: 506–515
Criteria for evaluating psychometric properties of
handwriting readiness measures
The quality criteria of Terwee et al.36 were used to assess the
psychometric properties of the instruments. For each property, a sample size of at least 50 participants is considered adequate. In our study, we evaluated the following psychometric
properties of an instrument.
Internal consistency
A positive rating was given when factor analysis was applied
and Cronbach’s alpha was between 0.70 and 0.95.
Content validity
A positive rating was given if a clear description was provided of
the measurement aim, the target population, the concepts that
were measured, and the item selection. In addition, the target
population should have been involved during item selection.
Criterion validity
A positive rating was given if convincing arguments were presented that the criterion standard was at least 0.70.
Construct validity
A positive rating was given when hypotheses were specified in
advance, and at least 75% of the results were in agreement
with these hypotheses.
Reproducibility agreement
A positive rating was given when the smallest detectable
change or the limits of agreement were smaller than the minimal important change. Because this is a relatively new
approach, a positive rating was also given if authors provided
convincing arguments that the agreement was acceptable.
Reproducibility reliability
A positive rating was given when the intraclass correlation
coefficient (ICC) or the weighted kappa was at least 0.70.
Responsiveness
A positive rating was given if hypotheses were given in advance
and at least 75% of the results were in accordance with the
hypotheses, and if the minimal important change was greater
than the smallest detectable change.
The criteria of Terwee et al.36 are based on classical psychometric testing. These do not include Rasch analysis, a method
that has recently become very popular in psychometric
research; therefore, this analysis was added to the reliability
and validity items of the Terwee et al.36 criteria. In addition to
these established psychometric properties36 the presence of
normative scores are of importance to determine whether a
score reflects normal or abnormal behaviour.
RESULTS
Selection of assessment tools
The search resulted in 1316 citations (Fig. S1, published
online). Duplicates were removed, narrowing the pool to 1114
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screening of the performance components of writing skills in
kindergarten children should focus on these two underlying
mechanisms.6
In the Netherlands, a valid and reliable occupation-based
assessment for writing readiness among kindergarten children
is lacking. The aim of this systematic literature review was to
investigate whether there are psychometric sound tests or
test items to assess handwriting readiness in 5- and 6-yearold kindergarten children at the level of occupations, activities ⁄ tasks and performance components.
Characteristics of assessment tools
The 12 instruments were grouped according to the
TCOP24,25 at the level of occupation, activities ⁄ tasks, and performance components (Table III).
There is only one occupation-based test that assesses the
aspects of handwriting readiness on the different levels of the
TCOP. The School-AMPS examines the interaction between
a student, a schoolwork task and a classroom environment
and evaluates the quality of the student’s schoolwork task
performance, measured at the level of complex activity and
occupation. Motor and process components of schoolwork
performance are evaluated by an occupational therapist
through observation in the classroom setting.40,41 From the
performance components perspective, only the aspect of fine
motor coordination is assessed.
Paper-and-pencil tasks
There are two instruments that involve one single paper–andpencil task: the SCRIPT17,18 and the DAP:QSS.42–47 The
SCRIPT is a letter shape copying test developed for kindergarten children.48 The child has to copy all 26 lowercase
letters and eight uppercase letters, namely, A, K, M, N, V, W,
Y, and Z. The DAP:QSS is a figure drawing assessment with a
quantitative scoring system.
One instrument was found that evaluates writing readiness
at the level of paper-and-pencil tasks and visual motor integration: the WESS-P.49 The WESS-P consists of four activities
reflecting pre-writing skills and conceptual development and
includes copying simple geometric shapes, copying speed,
copying letters and numbers, and name writing.
Fine motor coordination
Two instruments were found that consist only of a fine
motor coordination task: the TIHM-R50–53,53,54 and the
9HPT.55 Both tests use a time procedure with pegboard and
pegs. In the TIHM-R, the pegs must be used in in-hand
manipulation tasks, such as translation and rotation with stabilization; in the NHPT, the pegs must be used in a onehanded aiming task.
Visual motor integration
One test for the assessment of visual motor integration for this
population was found: the Beery VMI.1,17,19,44,48,56,57
General motor tests
Five general motor tests designed to measure fine and gross
motor skills in children were found: The MPC,58,59 M-ABC2,60,61 MMT,62 BOT-21,2,5,63–65,65,66 and Denver II.67,68
These tests evaluate fine and gross motor skills and include
items of writing readiness.
Psychometric properties of assessment tools
The psychometric properties for these 12 measures, which are
based on an extensive and systematic literature search, are
described in Table SII (published online). The psychometric
properties of an instrument are described according to the criteria of Terwee et al.36,69 Based on the accepted criteria, none
of the instruments demonstrated satisfactory results for all
properties (Table IV). The BOT-2 and the Beery VMI
showed the most satisfactory results in terms of psychometric
properties.
Feasibility
Feasibility was evaluated according to the amount of administration time needed to complete the test, the equipment
required, and the reliability of the recommended training time
to administer the test. These items are summarized in
Table II. The School-AMPS is the most time-consuming
approach because it consists of an interview with the teacher,
observation of two activities in the classroom, and interpretation of the scores. Training is required only for the SchoolAMPS.
Review
509
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citations. The preliminary selection, based on the abstracts,
contained 70 citations, with information about standardized
tests on school-occupations, paper-and-pencil activities ⁄ tasks,
fine motor coordination, and visual motor integration in kindergarten children aged 5 and 6 years.
We were unable to retrieve 11 articles via the university
library, and seven of the 70 citations were dissertation reports;
consequently, the preliminary selection was reduced to 52
full-text articles. Of these 52 articles, 26 were excluded because
information about a test was lacking (five articles), the test
included was not standardized (three articles), the test was not
handwriting-readiness specific (14 articles), or the participants
were older than 6 years (four articles). Citation and author
tracking resulted in an additional 14 articles being retrieved
and three manuals of included tests.37–39 The final selection
consisted of a total of 40 articles which included information
about standardized assessments on writing readiness in kindergarten children aged 5 and 6 years. We found 12 tests that
assess aspects of handwriting readiness in this age group. The
included measurements were (1) School Assessment of Motor
and Process Skills (School-AMPS); (2) Scale of Children’s
Readiness in Printing (SCRIPT); (3) Writing Essential Skill
Screener–Preschool version (WESS-P); (4) Test of In-Hand
Manipulation–revised (TIHM-R); (5) Nine Hole Peg Test
(9HPT); (6) Beery Developmental Test of Visual Motor Integration (Beery VMI); (7) Draw-A-Person: Quantitative Scoring System (DAP:QSS); (8) Motor Performance Checklist
(MPC); (9) Movement Assessment Battery for Children, 2nd
edition (M-ABC-2); (10) Maastricht’s Motor Test (MMT);
(11) Bruininks–Oseretsky Test of Motor Proficiency, 2nd edition (BOT-2); and (12) the Denver Developmental Screenings
Test, 2nd edition (Denver-II). We found information about
the first and second editions of the M-ABC and BOT. We
have chosen to include the second edition of these tests in this
review.
These 12 assessment tools were grouped according to target
population, objective, subscales, number of items (total and
handwriting-readiness specific), number of response options,
time to administer, required course, required materials, and citations in Pubmed, PsychINFO, CINAHL, and ERIC (Table II).
An individually
administered
measure of gross
and fine motor
skills
Identifies, describes,
and guides
treatment of motor
impairment
Evaluation tool for
measuring
student’s
schoolwork task
performance in
typical classroom
settings
4–21y
3–16y
3–12y
Movement
Assessment
Battery
for Children,
2nd edition
(M- ABC-2)60,61
School Version of
the Assessment of
motor and Process
Skills (SchoolAMPS)40,83
Measure a child’s
ability of in-hand
manipulation skills
(translation and
rotation)
Bruininks–Oseretsky
Test of Motor
Proficiency, 2nd
edition
(BOT-2)65,81,82
Test of In-hand
Manipulation–
Revised
(THIM-R)50–52
3 (3)
90 (90)
34 (34)
8 (3)
2 (2)
Manual dexterity.
Ball
manipulation skills.
Static and
dynamic
equilibrium
Pen ⁄ pencil
writing tasks.
Drawing and
coloring tasks.
Cutting and
pasting tasks.
Computer
writing tasks.
Manipulative
tasks
Fine manual control. 53 (20)
Manual
coordination.
Body
coordination.
Strength and
agility
Only one
Screen for visual
Visual motor
motor deficits
integration.
that can lead to
Visual
learning,
perception.
neuropsychological, Motor
and behavior
coordination
problems
2–18y
Beery
Developmental Test
for Visual Motor
Integration (Beery
VMI)1,17,19,44,48,56
Only one
Subscales
Measure a
child’s ability to
copy manuscript
alphabet letters
Objective
Kindergarten
Scale of Children’s
children
Readiness in
Printing (SCRIPT)17,18,50
Test
Age of
target
population
Number
of items
(nr of items
on writing
readiness)
4-point rating
scale
6-point rating
scale
Timed task
60–80
20–40
45–60
10
Testkit
Testkit
Pegboard
Test booklets
and pencil
Test booklet
and pencil
Materials
1wk course Test booklet
and pencil
No
No
No
No
0⁄1
25
No
Time to
administer Training
(min)
needed
0⁄1
Number
of
response
options
Table II: Classification of tests that assess aspects of handwriting readiness in 5- and 6-year-old kindergarten children
7
124
4
2
262
5
6
86
79
1
38
0
4
179
109
5
49
4
ERIC
PsychINFO CINAHL Pubmed
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510 Developmental Medicine & Child Neurology 2011, 53: 506–515
Review
A screening tool
designed for
children at risk of
developmental
problems
Screening for
preschool writing
skills
0–6y
4–5y
5–11y
5–6y
Denver
Developmental
Screenings Test–
2nd edition
(Denver II)67,68
Writing Essential
Skill Screener–
Preschool version
(WESS-P)49
Nine Hole Peg Test
(9HPT)55,84
Maastricht’s Motor
Test (MMT)62
Objectify qualitative
and quantitative
aspects of
movement
Measures fine
motor dexterity
Measure of mental
ability
3–15y
Draw A Person:
Quantitative
Scoring
System
(DAP:QSS)42–46
Screening for gross
and fine motor
problems
Objective
5y
Age of
target
population
Motor Performance
Checklist (MPC)58,59
Test
Table II: Continued
Static balance.
Dynamic balance.
Diadochokinesis.
Manual dexterity.
Only one
Gross motor.
Language.
Fine
motor–adaptive.
Personal–social
Only one
Only one
Subscales
70 (28)
1 (1)
125 (28)
1 (1)
12 (3)
Number
of items
(nr of items
on writing
readiness)
3-point rating
scale
Timed task
0⁄1
Counting
body
parts
0⁄1
Number
of
response
options
30
5
20–30
15
5
Time to
administer
(min)
No
No
No
No
No
Training
needed
Computer test
booklet
Pegboard with 9
pegs
Checklist,
interview,
observation
Paper, pencil,
test booklet
Checklist
and pencil
Materials
1
24
1
32
1034
1
ERIC
PsychINFO
0
117
0
62
17
0
CINAHL
1
122
0
352
181
2
Pubmed
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511
Performance components
Occupations
Paper-and-pencil activities
Fine motor coordination
Visual motor integration
School-AMPS40,83
SCRIPT17,18,48
WESS-P49
TIHM-R50–52,54
9HPT55,84
Beery VMI1,17,19,44,48,56,57
DAP:QSS85–87
MPC58,59
M-ABC-260,61
MMT62
BOT-21,2,5,63–65
Denver-II67,68
BOT-2, Bruininks–Oseretsky Test of Motor Proficiency, 2nd edition; Denver-II, Denver Developmental Screenings Test, 2nd edition; MMT,
Maastricht’s Motor Test; MPC, Motor Performance Checklist; DAP:QSS, Draw-A-Person: Quantitative Scoring System; School-AMPS, School
Assessment of Motor and Process Skills; SCRIPT, Scale of Children’s Readiness in Printing; TIHM-R, Test of In-Hand Manipulation–revised; Beery
VMI, Beery Developmental Test of Visual Motor Integration; WESS-P, Writing Essential Skill Screener–Preschool version; 9HPT, Nine Hole Peg
Test.
Table IV: Summary evaluation of psychometric quality of the instruments
Instrument
School-AMPS
SCRIPT
WESS-P
TIHM-R
9HPT
Beery VMI
DAP:QSS
MPC
M-ABC-2
MMT
BOT-2
Denver-II
Internal
consistency
0
0
+
0
?
+
0
0
0
0
+
0
Agreement
0
0
0
0
0
0
0
0
0
0
0
0
Test–retest
reliability
0
0
?
)
?
?
0
0
?
+a
+
?
Intrarater
reliability
+R
0
0
+R
0
0
0
?
?
+a
0
0
Interrater
reliability
0
0
0
0
?
?
0
?
?
?
+
?
Content
validity
+R
0
0
0
0
+
0
0
+
0
+
)
Construct
validity
(concurrent,
divergent)
a
+
+
?
+R
?
+
+
+
+
+
+
0
Criterion
validity
Responsiveness
0
0
+
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
?
0
In conformation with the quality criteria for measurement properties of Terwee et al.36 the rating is: +, positive rating; ?, indeterminate rating
(doubtful design); ), negative rating; 0, no information available. Doubtful design or method equals lack of a clear description of the design or
methods of the study, sample sizes smaller than 50 participants (should be at least 50 in every [subgroup] analysis), or any important
methodological weakness in the design or execution of the study. +a, design and results are adequate, but 30£n£50; +R, established with
Rasch-analysis; 9HPT, Nine Hole Peg Test; BOT-2, Bruininks–Oseretsky Test of Motor Proficiency, 2nd edition; Denver-II, Denver Developmental
Screenings Test, 2nd edition; DAP:QSS, Draw-A-Person: Quantitative Scoring System; M-ABC-2, Movement Assessment Battery for Children, 2nd
edition; MMT, Maastricht’s Motor Test; MPC, Motor Performance Checklist; School-AMPS, School Assessment of Motor and Process Skills;
SCRIPT, Scale of Children’s Readiness in Printing; TIHM-R, Test of In-Hand Manipulation–revised; Beery VMI, Beery Developmental Test of Visual
Motor Integration; WESS-P, Writing Essential Skill Screener–Preschool version.
DISCUSSION
This two-step systematic review of tests to assess handwriting
readiness in 5- and 6-year-old kindergarten children identified
12 measures with the School-AMPS as the only occupationbased assessment. None of the tests reviewed fulfilled all of
the criteria outlined against the TCOP, psychometric properties and feasibility.
512 Developmental Medicine & Child Neurology 2011, 53: 506–515
The School-AMPS is the only test that assesses paper-andpencil tasks at the level of occupation, activities, and performance components, according to the levels of the TCOP.
The importance of children’s participation in life situations is
gaining greater attention in the area of paediatric allied health
care.70 Therefore, we searched the literature for an occupation-based assessment of pre-writing activities useful in the
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Table III: Results classified on level of occupation according to the Taxonomic Code of Occupational Performance (TCOP)24,25
ity items.60 The fine motor part of the BOT-2 and the
M-ABC-2 should be a part of the assessment of writing readiness. The MPC, MMT and Denver II all have some items on
fine motor and paper-and-pencil tasks. If these items are to be
used as part of a writing readiness evaluation, research must be
carried out to validate their effectiveness as part of such an
assessment.
Based on content, the following seven tests should be useful
in an assessment of writing readiness: the School-AMPS,
SCRIPT, WESS-P, TIHM-R, Beery VMI, the M-ABC-2
and the fine motor part of the BOT-2.
Feasibility is one of the most significant variables influencing the actual use of an outcome measure in daily practice.79 A
quick, inexpensive, and nonintrusive assessment can be implemented in daily practice without impediment and is feasible
for therapists. However, the only occupation-based assessment
in this review, the School-AMPS, does have a problem: to
become a reliable and validated administrator of the SchoolAMPS, occupational therapy practitioners have to participate
in a 1-week training course and become calibrated as a reliable
rater. Rater calibration is a procedure that allows the AMPS
Project International to determine each rater’s competency
and whether or not they are scoring the School-AMPS in a
valid and reliable manner. This is a time-consuming and
financially burdensome criterion that may be a barrier for
some practitioners in daily practice.
In terms of psychometric properties, none of the instruments demonstrate satisfactory results for all properties,
according to the described criteria.36 From the seven tests that
can be useful in an assessment of writing readiness, the BOT2 and the Beery VMI show the most satisfactory results on
psychometric properties. All seven instruments that can be
used to assess aspects of writing readiness describe research on
construct validity. Only the BOT-2 shows positive ratings on
test–retest and interrater reliability, and the M-ABC-2 and the
Beery VMI show doubtful scores on these aspects. Interrater
and test–retest reliability are both very important aspects of
the stability of a test and the basis for further psychometric
research.80 However, until further reliability and validity studies are completed, therapists should be cautious in coming to
clinical decisions related to writing readiness of children based
solely on SCRIPT, WESS-P, and TIHM-R results.
There are several potential limitations to this review. Articles were included only if they were published in English, German, or Dutch. Therefore, some assessments may have been
excluded. The first selection was made on abstracts; thus, it is
theoretically possible that a handwriting readiness test could
have been missed. However, we checked the reference lists
from the included articles, so this is unlikely. The search
revealed very well-known tests that have proven useful for
assessing parts of the components of writing readiness. Finally,
the rating for Table IV was performed only by the first author
and, therefore, may be potentially biased.
CONCLUSION
The results of this systematic review identified only one
occupation-based assessment that assesses different aspects of
Review
513
14698749, 2011, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2010.03895.x by Cochrane Philippines, Wiley Online Library on [02/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
natural school setting where the environmental context can be
evaluated.23 Unfortunately, the School-AMPS does not comply with all the levels of the TCOP. There is no opportunity in
the School-AMPS to assess the qualitative ergonomic factors of
paper-and-pencil tasks, such as information about a static or
dynamic pencil grasp and information on an eventually forced
arm ⁄ hand position, which are important factors to evaluate during this developmental period of pencil grip and wrist pattern.31
Furthermore, the School-AMPS does not evaluate visual motor
integration, which is another important underlying component
of writing readiness identified in the literature.6
From the three tests which evaluated paper-and-pencil
tasks, copying ability, the domain of the SCRIPT, plays an
influential role in the primary stages of learning letter formation.48 Copying letters is believed to represent the majority of
handwriting activities performed by children in kindergarten,71 so this task should be included in an evaluation of writing readiness. Own name writing, an item in the WESS-P, is
an important early measure of emergent writing skill.72 Children learn how to print letters from their experience of writing
their own name.73 Consequently, own name writing should be
a specific part of the assessment of writing readiness.
The DAP:QSS, a figure drawing assessment, is used as an
indicator of cognitive level, socio-emotional development, and
personality,74 as well as an indicator of intelligence.45 The test
was not developed to be an indicator of early writing readiness;
therefore, we do not recommend that the DAP:QSS should be
part of a writing readiness assessment.
The two tests of fine motor coordination at the level of performance components that assess dexterity are the 9HPT and
TIHM-R. Time as duration of a task is the most widely used
index of dexterity and, therefore, the 9HPT is easy to use as a
dexterity test.55 In-hand manipulation is considered to be an
qualitative essential component of fine motor skills.30,75 A
positive relation between in-hand manipulation and the performance of functional activities, such as handwriting and the
use of scissors and cutlery, has been widely hypothesized.76
Case-Smith77,78 found that the time taken to rotate and translate pegs could be used to distinguish between children with
and without fine motor delay. Because the TIHM-R evaluates
fine motor coordination in a qualitative and quantitative way,
this test should be part of the assessment of writing readiness.
The Beery VMI is a test often used internationally for the
evaluation of visual motor integration. This test has been demonstrated to be particularly useful for the assessment of writing
readiness in 5- and 6-year-old children.17 Therefore, this test
should be part of the assessment of writing readiness.
General motor tests, such as the MPC, M-ABC-2, MMT,
BOT-2, and Denver-II, evaluate fine and gross motor skills,
including items of writing readiness. Only the M-ABC-2 and
the BOT-2 have subtests with a total score on fine motor, an
important performance component of writing readiness. The
BOT-2 has eight items on fine motor skills whereas the
M-ABC-2 has only three, suggesting that the fine motor score
of the BOT-2 is more stable. This attribute has been
confirmed by the authors of the M-ABC-2, who recommend
caution in drawing conclusions based solely on manual dexter-
tailored advice and interventions. The results of this systematic review identify test items which may be useful in the
development of a comprehensive evaluation tool of writing
readiness in children.
ONLINE MATERIAL/SUPPORTING INFORMATION
Additional material and supporting information may be found in the
online version of this article.
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